Pediatric Dental
Health

August 1, 2003

MANAGEMENT OF DENTAL TRAUMA IN CHILDREN Injuries to children’s
teeth can be very distressing for children as well as their parents. Dental
trauma may occur as a result of a sports mishap, an altercation, a fall inside
of the home, or other causes. Prompt treatment is essential for the long-term
health of an injured tooth. Obtaining dental care within 30 minutes can make the
difference between saving or loosing a tooth.

Causes and frequency of dental trauma
Approximately 30% of children have experienced dental injuries. Injuries to the
mouth include teeth that are: knocked out, fractured, forced out of position,
pushed up, or loosened. Root fracture and dental bone fractures can also occur.

The peak period for trauma to the primary teeth is 18 to 40 months of age,
because this is a time of increased mobility for the relatively uncoordinated
toddler. Injuries to primary teeth usually result from falls and collisions as
the child learns to walk and run.

With the permanent teeth: school-aged boys suffer trauma almost twice as
frequently as girls. Sports accidents and fights are the most common cause of
dental trauma in teenagers. The upper (maxillary) central incisors are the most
commonly injured teeth. Maxillary teeth protruding more than 4 mm are two to
three times as likely to suffer dental trauma than normally aligned teeth.

Medical history
Take a complete medical history. Assess the need for SBE prophylaxis.
Determine if the child has a bleeding disorder, or is immunocompromised.
Record any current medications. Question the parent about allergies to
medications. Obtain a history of any prior surgeries. Determine if the
child’s tetanus immunization is up-to-date. Determine if the child lost
consciousness due to the injury.

Dental history
The clinician should determine how, when, and where the injury occurred.
“How” is important because it provides information on the severity of
the injury. “When” is important, because the prognosis for the injured
tooth worsens with every minute of delay in treatment. “Where” is
important, because it may determine whether or not tetanus prophylaxis is
warranted.

Physical examination
A thorough examination is necessary to assess the full extent of all
injuries. Important information to be gathered for each patient includes:
vital signs, review of all systems, head and neck exam, and accident
information. It is important to rule out head injury, ocular damage, and
cervical spine injury. An evaluation of pupil size and reaction to light may
establish the presence of head injury.

Extraoral examination
The location and size of all extraoral and intraoral injuries must be
recorded. Palpate the mandible, zygoma, TMJ, and mastoid region. Ensure that
no mandibular or maxillary fractures are present. Find any mandibular
fractures by palpating the lower border of the mandible for a
“step-down” fracture. Record any extraoral lacerations, bruises, or
swelling. If a laceration is present in the upper or lower lip, the area
must be inspected for foreign bodies such as gravel or tooth fragments. Any
foreign bodies must be debrided from the soft tissue.
The mandibular condyles and maxilla should be carefully palpated. Check jaw
movements for normal range of movements. Chin lacerations require careful
evaluation of the cervical spine and mandibular condyles. Indications of
condylar fractures include: an anterior open bite, a malocclusion, or
limited mandibular opening. Confirmation of condylar fractures requires a
panoramic radiograph with closed – and open – mouth views.

Intraoral examination
All extraoral and intraoral clots and debris must be removed prior to
examining the oral soft and hard tissue. Palpate the alveolus to detect any
fractures. Have the patient clench the teeth so that the dental occlusion
can be evaluated. Each tooth should be examined for damage or mobility.
The labial mucosa, maxillary frenum, gingival tissues, and tongue should be
examined for bruising or lacerations. All intraoral lacerations must be
cleaned and explored, looking for any foreign bodies. The oral frenum, when
torn, will heal without long-term consequences. A tongue laceration should
be sutured if the tissue edges are not self-approximating. Most intraoral
impalement injuries will heal on their own – except for soft tissue
avulsion injuries.

Radiographic examination
For evaluating injuries to the maxillary or mandibular teeth, an occlusal
radiograph is the film of choice. If a root fracture is suspected,
radiographs at two different angles are required for a definite diagnosis.
For intruded teeth, a lateral anterior radiograph provides additional useful
information. A panoramic radiograph helps to evaluate suspected mandibular
or condylar fractures.

Photographic documentation
The use of preoperative and postoperative photography is very useful for
documentation purposes.

Knocked-out tooth
(dental avulsion)
A. DIAGNOSIS
A dental avulsion occurs when a tooth is completely displaced or knocked out
of the dental socket. Dental avulsion injuries occur most frequently in
children between the ages of 7 and 9, an age when the alveolar bone
surrounding the tooth is relatively resilient. Adult teeth that are avulsed
(knocked-out) should be considered for immediate replantation in order to
enhance the tooth’s long-term prognosis.

The best way to preserve a tooth that has been knocked out (avulsed) is to
put it back into its socket as quickly as possible. The single most
important factor to ensure a favorable outcome after replantation is the
speed with which the tooth is reimplanted. If immediate replantation isn't
possible, the tooth should be placed into a protective solution.

Avulsions are associated with poor post-treatment outcomes. Almost all
replanted teeth show replacement resorption and ankylosis – because
immediate replantation rarely happens. Replacement resorption leads to
fusion of the tooth root with the adjacent alveolar bone. In children who
have not achieved skeletal maturity, replacement resorption leads to
progressive infraocclusion (the tooth appears unerupted) during the
adolescent growth spurt.

Every tooth has a protective layer surrounding the root, which is called the
periodontal ligament. The periodontal ligament is very sensitive, and will
quickly dry out and die - unless the tooth is immediately placed in a
protective solution, such as milk or saline. With every minute that the
tooth is left out of the mouth to dry, more cells in the periodontal
ligament will die. After 15 minutes of dry storage, irreversible damage to
the periodontal cells (the root covering) occurs. If the cells of the
periodontal ligament are allowed to die, the child will eventually loose the
tooth. The goal of reimplanting the tooth into the socket is to preserve the
health of the tooth's outer periodontal ligament.

B. FIRST AID FOR AN AVULSED TOOTH
I. PRIMARY TOOTH

A primary tooth that has been avulsed is usually not reimplanted. The risk
of injury to the developing permanent tooth bud is high.
II. PERMANENT TOOTH

1. Do not touch the root of the tooth. Handle the tooth by the crown only.

2. Rinse the tooth off only if there is dirt covering it. Do not scrub or
scrape the tooth.

3. Attempt to reimplant the tooth into the socket with gentle pressure,
and hold it in position.

4. If unable to reimplant the tooth, place it in a protective transport
solution, such as Hank's solution, milk, or saline. This will hydrate and
nourish the periodontal ligament cells which are still attached to the root.
A small container of Hank's Balanced Salt Solution can be purchased in
dental emergency kit form at many drug stores. Contact lens solution is not
an acceptable storage medium.

5. The tooth should not be wrapped in tissue or cloth. The tooth should
never be allowed to dry.

6. Take the child to a dentist or hospital emergency room for evaluation
and treatment.

7. Radiographs may need to be taken of the airway, stomach, and mouth if
the tooth cannot be found .

8. Tetanus prophylaxis should be considered if the dental socket is
contaminated with debris.

5. Take a maxillary occlusal radiograph, as well as a lateral anterior
radiograph of the injured area. Consider taking a panoramic radiograph to
rule out condylar or mandibular fractures.

6. Gently aspirate the injured area without entering the socket. If a clot
is present, dislodge and remove it using light saline irrigation. Do not
curette the socket.

7. The tooth should be carefully held by the crown, and not by the root.
The avulsed tooth should be reintroduced into the dental socket slowly.

TOOTH REIMPLANTATION GUIDELINES

1. For A Mature Tooth With A Closed Apex: If the extraoral dry time is
<60 minutes, reimplant as soon as possible. If the extraoral dry time is
>60 minutes, soak in citric acid or curette the root; then soak in
stannous fluoride for 10 minutes. Rinse with saline. Perform root canal
therapy one week following the trauma.

2. For An Immature Tooth With An Open Apex: If the extraoral dry time is
<60 minutes, soak in doxycycline (1mg/20 ml saline) for 5 minutes. If the
extraoral dry time is >60 minutes, provide the same treatment as for a
closed apex.

3. Apply a flexible, functional splint for 7 to 10 days. If an alveolar
fracture is present, provide a very rigid splint for 4-6 weeks.

7. Provide analgesics to control pain. For children, consider prescribing
acetaminophen and codeine (Tylenol #3) for mild to moderate pain. The dose
is 15 mg/kg/dose of acetaminophen, every 4 hours. Do not exceed 2.6 g/day of
acetaminophen.

8. Arrange for tetanus vaccination if the wound was dirty, or if the
vaccination requires updating.

FOLLOW-UP CARE AFTER 7 TO 10 DAYS

1. For a tooth with an open apex, the goal is revascularization of the
pulp. For a tooth with an open apex and extraoral dry time <60 minutes:
no endodontic treatment is initially required. Re-evaluate every 3-4 weeks
for pathosis. In case of pulp pathosis, begin an apexification
procedure.>

2. For a tooth with an open apex and extraoral dry time >60 minutes:
begin an apexification procedure.

3. For a tooth with a closed apex: provide traditional endodontic
treatment and obturation. This is done to prevent of eliminate toxins from
entering the root canal space.

4. Remove the splint at this 7 to 10 day treatment visit.

5. Patients are recalled to the dental office every 3-4 weeks of
sensitivity testing. Thermal tests using difluorodichloromethane or “Endo
Ice” may be used.

6. Long-term follow-up is essential for 2 to 3 years after the
reimplantation procedure.

ENDODONTIC OBTURATION FOR AVULSED TEETH WITH CLOSED APICES

1. For a tooth with endodontic treatment started 7 to 10 days after
avulsion, obturate after 1 to 2 months of treatment with calcium hydroxide
paste.

2. For a tooth with radiographic signs of resorption or pathosis, or for a
tooth which had endodontic treatment started more than 14 days after the
avulsion, treat long term with a dense mix of calcium hydroxide. The calcium
hydroxide is changed about every 3 months. Obturate when an intact lamina
dura can be visualized.

Luxation involves displacement of a tooth in a labial, lingual, or lateral
direction. If the displacement is less than 5 mm, the dental pulp will
remain vital in about 50% of the cases.

Lateral luxation is an angular displacement of the tooth while it remains
within the socket. There is usually an associated fracture of the supporting
alveolar bone, especially with labial and palatal luxations.

An extrusion occurs when a tooth is only partially removed from the
socket. In the primary dentition, the alveolar bone surrounding the tooth is
relatively elastic, so the most common injury in toddlers is a dental
luxation (displacement injury) – with gingival hemorrhage. The primary
upper incisors are often pushed toward the palate during a fall.

B. FIRST AID
I. PRIMARY TOOTH
Place a cold wet cloth over the mouth, and bring the child to a dentist.
Provide pain relief by giving children’s Tylenol.
II. PERMANENT TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth to reduce
swelling. Give Tylenol for pain relief. Try to reposition the luxated tooth
back to its normal position using gentle to moderate finger pressure. The
patient is then instructed to gently hold the tooth in position. Obtain
definitive dental care as soon as possible.

C. DENTAL OFFICE TREATMENT
I. PRIMARY TOOTH

A primary tooth with a luxation in the labial direction needs to be
extracted, to avoid further damage to the developing permanent tooth bud.

In other cases, however, it is possible to splint the luxated primary
tooth back into normal position using a resin-modified glass ionomer cement.
The cement is mixed fairly thick, and placed on the labial and lingual
surfaces of the luxated tooth – and a few adjacent teeth. The luxated
tooth is held in the ideal position while the cement is setting. The splint
is removed after 10 days using a composite finishing bur.
II. PERMANENT TOOTH

For any severe luxation injury: an anti-inflammatory agent (Motrin), an
analgesic (Tylenol #3 or Percoset), and an antibiotic (Penicillin) are
prescribed.

For a lateral luxation, treatment includes: repositioning after local
anesthesia, and applying a semi-rigid splint for 2-3 weeks. A post-treatment
radiograph should be performed to assure proper position of the tooth in the
socket.

For an extrusive luxation, treatment includes: immediate repositioning and
placement of a semirigid (flexible) splint for 7-14 days.

Crown fractures comprise about 33% of injuries to primary teeth, and about
75% of injuries to permanent teeth. A crown fracture is classified based on
the location of the fracture in relation to the enamel, dentin, or pulp
tissue of the tooth.

If the fracture of the crown is incomplete, or if it produces cracks in
the enamel, it is referred to as an enamel craze, crack, or infraction. The
craze lines begin at the enamel surface and end at the enamel-dentin
junction.

The Ellis fracture classification has six categories, but only the first
three are commonly described in medical literature. An Ellis class I
fracture involves the enamel portion of the tooth, is rarely painful, and is
not a true emergency.
An Ellis class II fracture involves enamel as well as dentin, allowing the
entry of bacteria into the dentin tubules, as well as chemical or thermal
irritation of the pulp canal. Ellis class II fractures are recognized by the
yellow to pink color of the dentin.

In an Ellis Class III fracture (severe), the dental pulp is exposed –
requiring immediate care. The fracture site will have a reddish tinge or
will show bleeding. In an Ellis class III dental fracture, exposure of the
pulp’s nerve endings can cause extrement pain – even if exposed only to
air. Exposure of the pulp in an Ellis class III fracture will eventually
lead to pulpal necrosis from bacterial infection, if left untreated.

B. FIRST AID
I. PRIMARY TOOTH
Have the child rinse with warm water. Use a cold cloth or ice pack to reduce
swelling. Use acetaminophen for pain, not aspirin. Cover any severe fracture
with a biocompatible cement or dressing until a dentist can treat the
problem.
II. PERMANENT TOOTH
Have the child rinse with warm water. Use a cold cloth or ice pack to reduce
swelling. Use acetaminophen for pain, not aspirin. Cover any severe fracture
with a biocompatible cement or dressing until a dentist can treat the
problem.

The indication for a partial (Cvek) pulpotomy is: a small and recent
pulpal exposure less than 2 weeks old. A diamond bur or a 330 carbide bur is
used to amputate the pulp to a depth of 2 mm. Only saline irrigation is used
to achieve hemostasis. Then calcium hydroxide paste is placed, followed by a
glass ionomer cement to seal the area.
Recalls are scheduled at 1, 3, and 6 month intervals.

Indications for a deep cervical pulpotomy include:
a large pulpal exposure, pulpal exposures older than 2 weeks, or if
hemostasis cannot be obtained during a Cvek pulpotomy procedure. Formocresol
or ferric sulfate is used to obtain hemostasis during a deep cervical
pulpotomy. ZOE paste or glass ionomer is used to seal the area.

When the trauma has resulted in chronic inflammation or necrosis of the
pulp, a pulpectomy should be considered.
II. PERMANENT TOOTH

Treatment for a case of enamel infraction consists of sealing the cracks
– using any enamel adhesive system.

For an Ellis class I dental fracture, dental care involves removing the
sharp edges to prevent injury to the soft tissues of the mouth.
Alternatively, the fracture may be restored with composite material.

For an Ellis class II fracture, the dentin should be coated with a
protective covering, such as a RMGI or Fuji IX cement – as an interim
measure. Allow up to 8 weeks for the injured tooth to recover before placing
the final composite restoration.

For an Ellis class III complex fracture of the permanent tooth, the main
goal is to retain a viable dental pulp, and permit completion of root
growth. Therefore, if the pulp exposure is very recent or very small, a
direct pulp cap may be performed. For an exposure larger than 2mm, a Cvek
pulpotomy may be performed, removing only a millimeter or two of infected
pulp tissue. The Cvek technique consists of using a round diamond bur,
amputating the exposed pulp tissue to a depth of 1-2 mm, passively covering
the healthy pulp with calcium hydroxide. Then, the area is sealed with a
RMGI or composite material.
For an exposure older than two hours, a cervical-depth pulpotomy may be
needed – ideally using only saline irrigation to achieve hemostasis.

Tooth pushed up
(dental intrusion)
A. DIAGNOSIS

An intrusion injury is the most severe type of luxation injury. The
intruded tooth is impacted into the alveolar bone, and the alveolar socket
is fractured. The forces that drive the tooth into the socket wall crush the
periodontal ligament, and rupture the blood and nerve supply to the teeth.
The tooth may not be visible, and can be mistaken for an avulsion.

Some studies have shown that intrusions of up to 3 mmm have an excellent
prognosis, whereas the prognosis of incisors with severe intrusions (>
6mm) is hopeless. If a permanent tooth is involved, radiographs may show an
alveolar fracture, or tooth displacement into the nasal cavity. Pulpal
necrosis (death of the dental pulp) occurs in 96% of cases of intruded
permanent teeth.

If a primary incisor is involved in an intrusion injury, a lateral
anterior radiograph (“mini-ceph”) should be taken of the traumatized
region to determine the proximity of the intruded primary root tip to the
developing adult tooth bud.

B. FIRST AID
I. PRIMARY TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth to reduce
swelling. Give Tylenol for pain relief.
II. PERMANENT TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth to reduce
swelling. Give Tylenol for pain relief.

C. DENTAL OFFICE TREATMENT
I. PRIMARY TOOTH

Allow the primary tooth to spontaneously erupt over a 2 to 3 month period
- as long as the developing permanent tooth bud has not been injured. If
re-eruption does not begin within 2 months, extraction of the intruded
primary tooth will be necessary.

A very intruded primary incisor, whose root tip is displaced into the
developing permanent tooth should be extracted. Extraction of the intruded
tooth will prevent further damage or hypoplasia to the adult tooth bud.
II. PERMANENT TOOTH

Current management strategies for intruded permanent incisors include:
surgical reduction (immediate repositioning), repositioning with traction
(active repositioning), and waiting for the tooth to return to it pre-injury
position ( passive repositioning).

Incisors intruded less than 3mm may be allowed to reposition themselves.

Incisors intruded between 3 –6 mm are unpredictable, but they may be
orthodontically extruded within 3-6 weeks.

Incisors that have been intruded beyond 6 mm should be immediately
repositioned (surgically) to their normal position – followed by root
canal treatment.

Root canal treatment is recommended in permanent teeth with complete root
development. If there is any doubt about pulp vitality, or if root
resorption begins, then a pulpectomy must be performed, followed by interim
placement of intra-canal calcium hydroxide. After apical closure and root
health are confirmed, the canal is filled with a standard root canal
material (gutta percha).

Tooth was hit (subluxation, dental concussion)
A. DIAGNOSIS
Concussion results in mild injury to the periodontal ligament without tooth
mobility or displacement. Subluxation causes significant injury to the
periodontal ligament , resulting in some tooth mobility. There is usually
bleeding at the marginal gingival, and the tooth is tender to percussion in
subluxation.

A baby tooth may change color after being subjected to trauma. A front tooth
can be traumatized during a fall, while running into furniture, while
engaging in rough play, or from impact with a blunt object. Dental trauma
affects the blood supply to the tooth, and therefore its health and color.
Different color changes suggest specific problems with traumatized baby
teeth (primary incisors). Such teeth may turn dark, but in many cases the
color will change back to normal after a few months. Traumatized primary
incisors may develop yellow, grey, or pink discolorations.

A yellow or yellow-brown discoloration indicates calcification and
obliteration of the dental pulp (nerve canal). No treatment is usually
needed with this type of discoloration.
A grey or black discoloration indicates necrosis (death) of the dental pulp
in 98% of cases. Such teeth will usually require root canal treatment or
extraction.
A pink tooth indicates either internal resorption, or the presence of blood
pigments in the dentinal tubules of the tooth. The pink tooth needs to be
monitored closely.
Treatment of a discolored primary incisor may involve periodic radiographic
and clinical evaluation, root canal treatment, or extraction of the tooth -
depending on the health of the tooth and the child's ability to cooperate
with dental treatment.

B. FIRST AID
I. PRIMARY TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth to reduce
swelling. Give Tylenol for pain relief.
II. PERMANENT TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth to reduce
swelling. Give Tylenol for pain relief.

C. DENTAL OFFICE TREATMENT
I. PRIMARY TOOTH
Radiographs are taken to rule out root fractures. The child is then put on a
soft diet for a week, at the end of which a recall exam is performed.
II. PERMANENT TOOTH
If the tooth is very mobile, and can be moved more than 2mm, a flexible wire
and composite splint may be placed for 7-10 days.

Root fracture
(apical, mid-root, cervical)
A. DIAGNOSIS

Root fractures occur in only 7% of dental injuries. Horizontal root
fractures occur in anterior teeth, and are caused by direct trauma. Vertical
root fractures usually occur in molars, and may be caused by clenching or
trauma to the mandible. Vertical root fractures are more difficult to
detect, and may not be found until extensive tooth destruction has occurred.

A horizontal root fracture is classified based on the location of the
fracture in relation to the root tip (apex). Horizontal root fractures may
occur in:
the apical third, middle third, or cervical third of the root.
The prognosis worsens the further cervically (towards the crown) the
fracture has occurred. Tooth fractures are often not apparent during a
clinical examination, and can usually only be diagnosed using appropriate
radiographs. Radiographs with at least two views are required for making
this diagnosis.

B. FIRST AID
I. PRIMARY TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth to reduce
swelling. Give Tylenol for pain relief.
II. PERMANENT TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth to reduce
swelling. Give Tylenol for pain relief.

C. DENTAL OFFICE TREATMENT
I. PRIMARY TOOTH
As long as no abscess or excessive mobility occurs, the primary tooth with a
fractured root can simply be monitored for health. If a portion of the root
is abscessed or extremely mobile, it can be extracted, and the remaining
root fragment will resorb normally. For coronal third fractures in primary
teeth, the coronal third is extracted, leaving the apical portion of the
root to resorb normally. Do not “chase” apical third fragments.
II. PERMANENT TOOTH

The most important factor in the success and treatment of a horizontal
root fracture is the immediate reduction of the fractured segments, and
complete immobilization of the coronal segment. Root fractures must be
diagnosed before the body tries to “repair” the problem, and before the
blood clot prevents apposition of the fractured segments. If more than 24-72
hours have elapsed, it may be impossible to obtain close apposition of the
segments.

Treatment for horizontal root fractures consists of rigid fixation
(immobilization) in an attempt to get the cementum and dentin to heal. The
tooth is splinted to the adjacent normal teeth with a very rigid wire and
composite splint for 8 weeks. Serial radiographs are then taken a 6 month
intervals after the splint is removed.

B. FIRST AID
I. PRIMARY TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth to reduce
swelling. Give Tylenol for pain relief.
II. PERMANENT TOOTH
Rinse with cold water, and keep an ice pack over the lip and mouth to reduce
swelling. Give Tylenol for pain relief.

C. DENTAL OFFICE TREATMENT
I. PRIMARY TOOTH

For any severe luxation injury: an anti-inflammatory agent (Motrin), an
analgesic (Tylenol #3), and an antibiotic (Penicillin) are prescribed.

Treatment of alveolar process fractures requires manually repositioning
the segment of displaced teeth back into proper arch alignment. A very rigid
splint is applied for two months.
II. PERMANENT TOOTH

For any severe luxation injury: an anti-inflammatory agent (Motrin), an
analgesic (Tylenol #3 or Percoset), and an antibiotic (Penicillin) are
prescribed.

Treatment of alveolar process fractures requires manually repositioning
the segment of displaced teeth back into proper arch alignment. A very rigid
splint is applied for two months.

Prevention of dental injuries
Dental injuries increase sixfold to eightfold when mouth protection is not
used. Education of athletes and coaches may encourage greater use of
mouthguards. Educating physicians and the public about first aid for dental
injuries may reduce complications later.

Recent journal article
A journal article in Contemporary Pediatrics reviews the
management of trauma to primary teeth. The article lists the medical billing
codes for dental trauma and discusses management of different types of
trauma to the hard and soft oral tissue in young children. Evaluation,
examination, and treatment of injuries to the primary dentition is covered.